ACT Questions and Answers - September 18, 2019

The following questions and answers (Q&As) are cumulative from the Ask the Contractor Teleconference (ACT). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. Due to an unfortunate technical difficulty with the webinar reports following the event, the below includes the pre-submitted Q&As only. Providers are encouraged to call the Provider Contact Center (PCC) with questions. Noridian sincerely apologizes for any inconvenience.

Q1. Is the anticipated length required to be documented as part of an inpatient admission physician order?
A1. No.

Q2. What is the process to request a CPT code be removed from a Local Coverage Determination (LCD)? Is this the same as the LCD Reconsideration Process? What supporting material is needed to substantiate the request?
A2. Yes. See the LCD Reconsideration Process webpage for details. Justification for the proposed change must be supported by peer-reviewed medical literature published in scientific journals and in full-text (no abstracts, presentations, etc).

Q3. We have a Partial Hospitalization Program (PHP) and provide four group services per day, five days a week. Each group service is one-hour long to meet the minimum 20 hours per week requirement. Is it permissible to provide an individual psychotherapy session if a patient misses a group session?
A3. Yes.

Q4. An inpatient order is not signed prior to patient discharge and the patient reverts to outpatient status. If the provider signs the order at any point after the patient discharges, does this instruction apply?
A4. Yes. Authentication of the order is required prior to discharge and may be performed and documented as part of the physician certification.

Q5. When a patient loses his/her Medicare Beneficiary Identifier (MBI) card, will Medicare issue a new card with a new number?
A5. Yes. There is an established process for when the patient loses their new Medicare card. Visit for a detailed process for beneficiaries.

Q6. Our Medicare Advantage (MA) shadow claims contain services outside of the 72-hour guideline for Medicare. The MA plans require services within 30 days to bundled for billing purposes but this causes the claim to edit in the Medicare system. How can this be avoided with these shadow claims?
A6. All claims submitted must follow Medicare regulations. Providers are encouraged to work with the individual MA plans regarding their claims processing guidelines.

Q7. If a patient is seen outpatient as a referral for a shoulder issue and then discusses his/her instability or balance issues, is the physician to treat for both diagnoses?
A7. The evaluation should be comprehensive. Complete only one evaluation.

Q8. What is the process with mammography certification for providers? To bill for those services, what is the typical timeframe for this to reflect?
A8. Providers that furnish film, digital, or 3-D mammography services and bill Medicare for these services must have their mammography certification up to date. Contact the Provider Contact Center (PCC) to see if the certification is on file.

Q9. We bill HCPCS J9190 and chemo administration CPT 96416. Noridian indicates that this is not acceptable as of July 2019. Coding says this combination is correct, can Noridian confirm?
A9. Effective January 1, 2016, CPT 96416 is no longer valid for Medicare. When used with the chemotherapy drugs listed in our Chemotherapy Administration articles, bill HCPCS G0498.


            Last Updated Mon, 21 Oct 2019 08:32:48 +0000